Cholesteatoma

Review by L Flood
Middlesborough, UK

It is a challenge to say something new about cholesteatoma in print, but this publication meets that challenge very well. It is based on the authors10-year experience of running instructional courses, at each of the annual meetings of the AAOHNS, and that shows through. The 150 pages are filled with practical tips, not the rambling, almost philosophical, monologues that one can see elsewhere. I welcomed an early comment that cholesteatoma does not lend itself to a cookbook approachand that only rarely does one find that one size fits all. There are those who will start any account of mastoid surgery with the words Well, I always…’, because it has worked in their hands. How much better to have a range of approaches, tailored to the patient and the disease process? (Hang on, I am dipping into philosophy myself!)

This is very much a surgical text, with only the opening chapter devoted to the basic science of the disease. The next four chapters cover the approach to the middle-ear cleft and the fashioning of an ideal cavity. Chapter 8 is particularly good in discussing controversies, such as intact versus canal wall down, endoscopes, the facial nerve monitor (commonplaceversus an adjunctbut no more than that?) and the need for a second look.

The book has several high quality illustrations on every single page, whether endoscopic views of the drum, peri-operative microscopy views, sectional anatomy or line drawings. I have never thought cholesteatoma the most photogenic of subjects. White, wet keratin against creamy bone, in a bloodbath, is hardly appealing, but these authors manage it. I almost expected colour in the CT scans! Tympanoplasty I have always found equally difficult to capture with the camera. One is so grateful to see the graft in place that it is tempting to pack fast before the corpuscles flow. Again, the authors have produced excellent pictures of myringoplasty and ossiculoplasty. I was intrigued by the idea of laser contraction applied to an atrophic tympanic membrane flapping in the breeze. So simple, but I confess I have never heard of it before.

Chapter 7, ‘Hearing issues’, is brief but my favourite. The intact ossicular chain, the diseased better hearing ear, or, worse, the only hearing ear – all require the judgement of Solomon.

Finally, there are the on-line videos, 25 in all, of surgical procedures. A casual browser might easily miss the second page with the scratchcard access to registration. Obviously, the videos provide invaluable back-up to the text on such issues as the canal fistula, brain herniation and dissecting off the exposed facial nerve.

While your Euros are still legal tender and worth something, this book is an excellent investment for both the trainee and the most experienced surgeon. It is not a lab-based dissection guide; it is instead about thinking and judgement in the management of this challenging problem.

Amazon Link: Cholesteatoma
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